DSM-5 – Coming May 2013

Written by Geoff Kane, MD, MPH. Posted on
October 2, 2012

Addiction treatment and other mental health professionals are accustomed to applying the diagnostic criteria published by the American Psychiatric Association (APA) in the 1994 Diagnostic and Statistical Manual of Mental Disorders Fourth Edition (DSM-IV) and the 2000 “Text Revision” version of the same compendium (DSM-IV-TR), which updated the narrative material but kept the same diagnostic criteria. Criteria in the substance-related disorders section of DSM-IV are all the more familiar to veterans in the addiction field because they were barely changed from the criteria in the previous DSM, the 1987 “Revision” of the Diagnostic and Statistical Manual Version III (DSM-III-R).

The names we give diseases are no more than useful categories for grouping individuals whose ailments have similar physical or behavioral manifestations or similar causes, and that respond to similar therapeutic or preventive efforts. Disease names and criteria to diagnose them evolve because scientific knowledge and technology evolve. Revisions of classifications and criteria are necessary when developments in science and technology, along with accumulated practical experience, suggest that alternative names and criteria will be more relevant and useful than those in use.

The next edition of the DSM is scheduled for release in May 2013. It is the product of an APA work group, which solicited input from mental health professionals in general and from the public. Besides a tendency to identify the new version by the Arabic number “5” rather than the Roman numeral “V”, what can we expect?

The DSM-IV diagnostic category (and chapter heading) Substance-Related Disorders will likely become Substance Use and Addictive Disorders. Many of the disorders within this DSM-5 category are specific to substances (such as alcohol or opioids) just as they were in DSM-IV. Gambling disorder is to be classified as a non-substance or behavioral addiction; pathological gambling was previously classified as an impulse-control disorder. Other non-substance addictions were reviewed but did not meet the criteria of the APA work group for inclusion at this time. Internet use disorder is tagged for further study.

The major change proposed for DSM-5 is to replace the two separate DSM-IV (substance specific) categories of dependence and abuse with a single (substance specific) category, substance use disorder (SUD). The criteria for substance use disorder merge the previous lists of seven dependence criteria and four abuse criteria into a single list of eleven criteria, but drop the criterion of recurrent legal problems and add a criterion for craving. Severity of illness is graded by the number of criteria met: 0 to 1, no diagnosis; 2 to 3, mild SUD; 4 to 5, moderate SUD; 6 or more, severe SUD.

Tolerance and withdrawal will not count if an individual is taking a medicine such as an opioid analgesic under medical supervision. This change should reduce the mislabeling of patients as dependent or addicted when they develop normal physiological dependence while adhering to a prescribed regimen.

The formal recognition of mild-moderate-severe subgroups of people with substance use disorders may promote greater precision in research and ultimately improve the care of patients. For example, some studies on the outcomes of treatment for alcohol problems have not even separated subjects by alcohol abuse and alcohol dependence. The overall results of these studies may suggest it doesn’t matter whether treatment is outpatient or inpatient/residential, but the needs of patients at the severe end of the spectrum, who may require more intensive treatment, may have been imperceptible because they were analyzed with everyone else.

Also expect controversy over DSM-5. For example, there has been extended deliberation on the relative merits of the terms addiction and dependence; this may or may not be resolved with the choice of the term SUD. The late Griffith Edwards was reluctant to abandon the separate categories of dependence and abuse and worried the new DSM would no longer correlate well with the International Classification of Diseases (ICD). Other authors have respectfully discounted his concerns. [O’Brien,Hasin, Schuckit]

Regardless of disagreement on names and classifications, kudos to the APA work group because they strive not only for clear language but also for language that will not stigmatize the individuals who meet criteria for these disorders. A different issue that by now should be beyond controversy is the “disease-ness” of these disorders. Acceptable disease categories must fit with current science and technology and be relevant and useful. Substance Use and Addictive Disorders do that.